24 CHANDLER RD - BUILDING PERMIT APP '19 ( ,Sz
nwealth of Massachusetts ED
q Hoard or't3u fflmg Regulations and Standards IN PECf=SERVICES
Massachusetts State Building Code, 780 CMR/ Revised Mar 2011
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Building Permit Application To Construct, Repair, Renovate Or Demolish a t I4 MAY —9 A OO
One-or Two-Family Dwelling
_ This Section For Official Use Only
Building Permit Number: Dat plied: `i e
Building Official(Print Name) Sign Date
SECTION 1:SITE INFORMATION
1.1 Property ddress: 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
Y.3,�ZZoning Information: 1.4 Property Dimensions:
-.—a,t---- �5-- ------- -- -— -- - ------
Zoning District Proposed Use Lot Alen(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood "Lone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood`Lone'?Check if ves❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
Q 1Q 4 iM nn r2fTlJ D 5 S rt 1 �� t�/5 -
�ume int) City,State,ZIP
No.and Street 'telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Id .Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': ywo3CL_
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 9 000 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ / 60D .—
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ ,3 000, 2. Other Fees: $
4. Mechanical (FIVAC) $ List:_
S. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 000 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Cdnstruction Supervisor License(CSL)
CS-ozzy6� �/6
�TP—o (T License Number pir lion Date
Name of CSL Holler
/2J List CSL Type(see below)
No.and Street Type Description
J ''nnnn U Unrestricted(Buildings u to 35,000 cu.ft.)
25;4, /dial R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
t Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 171v7 3 �/
�azL S o(/� GFY • C612 r< HIC Registration Num Expinition Date
HIC Company Name or HIC Registrant,N, e
No.and Street Email address
S L-C?tic/ A)4- )7y- g)V- z/
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit mu be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the 1 uance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under t&painsd penalties of perjury that all of the information
contained in thiss application is true and acc ate[omy nowledge and understandi✓ng.
J JPrint Owners or Authorized Ag, ilea ate
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost'